Attachment styles are used to describe patterns of attachment in relationships. Adults with a secure attachment style tend to have good self-esteem, they share their feelings with partners and friends, and have trusting, lasting relationships. Insecure attachment styles include anxious attachment style (also known as ambivalent or preoccupied), which involves reluctance to become close to others, worry about the security of relationships, a reduced sense of autonomy, and increased dependence on others. Avoidant attachment style is another insecure style. It involves problems with intimacy, over-regulation of emotions, and unwillingness to share thoughts and feelings. Fearful attachment style is represented by an inconsistent sense of self and an inability to regulate one’s emotions.

While attachment style in adulthood is thought to be based on early experiences with primary care givers, life’s experiences can also impact on attachment style in adults. Children described as ambivalent or avoidant can become securely attached as adults, while those with a secure attachment in childhood can show insecure attachment patterns in adulthood.

What is the evidence for attachment styles in people with bipolar disorder?

Moderate to high quality evidence finds a large effect of more insecure attachment styles in people with bipolar disorder compared to controls. This effect was similar to that seen in people with depression or schizophrenia. It was also similar across all three disorders for anxious attachment style. However, for avoidant attachment style, it was small for schizophrenia, medium-sized for bipolar disorder, and large for depression.

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Bipolar disorder is characterised by recurrent episodes of depression and mania, hypomania, or mixed symptoms. A major depressive episode is a period of at least two weeks in which a person has at least five of the following symptoms (including one of the first two): intense sadness or despair; feelings of helplessness, hopelessness or worthlessness; loss of interest in activities once enjoyed; feelings of guilt, restlessness or agitation; sleeping too little or too much; slowed speech or movements; changes in appetite; loss of energy; difficulty concentrating, remembering or making decisions; and/or thoughts of death or suicide. Long-term studies have found that depressive symptoms are usually more pervasive than mood elevation or mixed symptoms. Depressive symptoms have also been consistently associated with greatest impairments in social and occupational functioning.

What is the evidence for bipolar depression?

High quality evidence shows an earlier age of illness onset of bipolar disorder is associated with increased severity of depression. Moderate to high quality evidence shows depression episodes are around three times more common than mania, elevated, or mixed episodes over the course of bipolar disorder. Factors associated with depression predominance are; type II bipolar disorder, melancholia symptoms, a depressive onset of illness, suicide attempts, mixed episodes, and delayed diagnosis of bipolar disorder.

Moderate quality evidence suggests the factors associated with bipolar depression rather than unipolar depression in children or youth include; more psychiatric comorbidities and behavioural problems (oppositional disorder, conduct disorder, anxiety disorders, irritability, suicidal/self-harm, social impairment, and substance use); earlier onset of mood symptoms; more severe depression; and having a family history of psychiatric illness.

Moderate to low quality evidence suggests the cumulative rate of conversion from unipolar depression to bipolar disorder increases from 3.78% at 1 year assessment to 12.87% at 10 year assessment. However, the yearly rate of conversion from unipolar depression to bipolar disorder decreases from 3.83% at 1 year assessment to 0.78% at 10 year assessment.

Moderate quality evidence finds no differences in levels of anhedonia (reduced capacity for pleasure) between people with bipolar disorder and people without a mental illness. Levels of anhedonia were higher only in people with schizophrenia, major depression (not remitted), substance use, and Parkinson’s disease when compared to people without a mental illness.

September 2021

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Key features of the symptoms of disorganisation include disorganised speech and behaviour, as well as inappropriate affect. Severely disorganised speech is difficult to follow, being incoherent, irrelevant and/or illogical. These symptoms are sometimes called positive formal thought disorder symptoms. Disorganised speech may also be deprived of content, which is sometimes called negative formal thought disorder symptoms. Disorganised behaviour includes bizarre or inappropriate behaviour, actions or gestures. Inappropriate (incongruous) affect involves exhibiting incorrect emotional responses for a given context. Symptoms of disorganisation have been identified as risk factors for poor illness outcome, and have a significant negative effect on a person’s day-to-day functioning and quality of life. There is evidence to suggest that disorganisation symptoms may be associated with impaired cognition.

What is the evidence for disorganised symptoms in people with bipolar disorder?

Moderate to high quality evidence suggests a small to medium-sized effect of less formal thought disorder in people with bipolar disorder than in people with schizophrenia. This effect is significant only in non-acute, stable patients.

October 2021

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Dissociation is described as disruption or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, or behaviour. Common dissociative experiences include mild forms of absorption, such as daydreaming. Less common and more severe dissociative experiences include amnesia, derealisation, depersonalisation, and fragmentation of identity. Dissociative features may play a role in the pathology of bipolar disorder.

What is the evidence for dissociation symptoms in people with bipolar disorder?

Moderate to low quality evidence suggests less dissociation in people with the disorder than in people with dissociative disorders, post-traumatic stress disorder, borderline personality disorder, or conversion disorder. Similar scores were found in people with bipolar disorder and in people with other affective disorders, somatic symptom disorder, substance-related and addictive disorders, eating disorders, and schizophrenia.

October 2021

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Early detection of bipolar disorder can prevent or delay the onset of the disorder, and improve clinical outcomes in people who develop it.

What is the evidence regarding early detection of bipolar disorder?

Moderate to high quality evidence suggests large effects of having psychotic symptoms or a family history of bipolar disorder as risk factors for transition to bipolar disorder in people with major depression. There was a medium-sized effect of higher risk of transition to bipolar disorder with early age of onset of depression, and a small effect of having a family history of any mood disorder. The risk of transition to bipolar disorder was greatest in the early stages of having a major depressive disorder (up to 5 years).

Moderate quality evidence suggests subclinical symptoms preceding an initial mood episode last around 27 months, and subclinical symptoms preceding a recurrent mood episode last around 1 month. Common subclinical symptoms (in order of decreasing prevalence) are too much energy, diminished ability to think, indecisiveness, pressured speech, talkative, elated mood, academic or work difficulties, insomnia and depressed mood. Less common subclinical symptoms (in order of decreasing prevalence) are over-productive/goal-directed behaviour, agitation, rage attacks, racing thoughts, anxiety, decreased need for sleep, irritable mood, fatigue, distractibility, sleep disturbance, disinhibition, weight loss/loss of appetite, hyperactivity, suicidal thoughts, feeling of worthlessness, mood swings, delusions, unkempt or bizarre appearance, guilt, and auditory hallucinations. Rare subclinical symptoms (in order of decreasing prevalence) are loss of interest, somatic complaints, being over-sensitive, hypersexuality, flight of ideas, hypersomnia, weight gain, self-harm, suicide attempts, and visual hallucinations.

Low quality evidence is unable to determine the accuracy of instruments used for early detection. Review authors conclude that the Child Behavioral Checklist – Pediatric Bipolar Disorder Phenotype and the General Behavioral Inventory – Revised have the better validity and utility than the Hypomanic Personality Scale, the Behavioral Activation Scale or the Family History Scale, and that more studies assessing these scales are required.

September 2021

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A manic episode is a period of at least one week when a person is high spirited or irritable in an extreme way most of the day for most days. A manic episode involves changes in normal behaviour, including showing exaggerated self-esteem or grandiosity, less need for sleep, talking more than usual, talking more loudly and quickly, being easily distracted, doing many activities at once, scheduling more events in a day than can be accomplished, embarking on risky behaviour, uncontrollable racing thoughts, and/or quickly changing ideas or topics. These changes in behaviour are significant and clear to friends and family and are severe enough to cause major dysfunction. A hypomanic episode is similar to a manic episode but the symptoms are less severe and need only last four days in a row. Hypomanic symptoms do not lead to the major problems that mania often causes, and the person is still able to function. The frequency and severity of manic or hypomanic symptoms vary from person to person, and may also vary according to whether the onset of bipolar disorder is in childhood, adolescence, or adulthood.

What is the evidence for mania symptoms in bipolar disorder?

Moderate quality evidence finds the most common mania symptoms reported in youths with bipolar disorder are (in decreasing order); increased energy, irritability, mood lability, distractibility, goal-directed activity, euphoric/elated mood, pressured speech, hyperactivity, racing thoughts, poor judgment, grandiosity, inappropriate laughter, decreased need for sleep, and flight of ideas. Moderate to high quality evidence finds irritability, aggression, and low insight are more common in youths than adults with bipolar disorder. Odd appearance, grandiosity, flight of ideas, decreased sleep, and increased sexual interest are more common in adults with bipolar disorder.

Moderate to high quality evidence finds having a positive family history of any mood disorder is associated with greater likelihood of switching to mania in children with major depression. Moderate quality evidence suggests having subthreshold symptoms of mania, emotional dysregulation, or behaviour problems are also associated with greater likelihood of switching to mania in children with major depression.

In adults with bipolar disorder, moderate to low quality evidence shows increased prior depressive episodes was associated with increased risk of antidepressant-induced mania.

September 2021

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Minor physical anomalies (MPAs) are subtle anatomical deviations which have little functional or aesthetic impact. MPAs in people with bipolar disorder are highly variable, but may include high palate, low-seated ears, cuspidal ear (ears with angled ridges instead of a round curve at the top of the opening into the ear canal), strabismus (cross-eyes), hypertelorism (increased distance between the eyes) and adherent, or attached ear lobes. They may be traced to events occurring prenatally and may represent risk markers for underlying illness susceptibility. MPAs may be important risk indicators when an individual is already at high risk of developing a mental disorder and when multiple MPAs occur together in one individual.

What is the evidence for minor physical anomalies in people with bipolar disorder?

Moderate quality evidence finds more anomalies in the head and facial region of people with bipolar disorder compared to controls, with no differences in peripheral regions.

December 2021

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Bipolar disorder is characterised by recurrent episodes of depression and mania. Some people with bipolar disorder also show episodes of mixed symptoms or states. Mixed states involves having three or more manic/hypomanic symptoms within a depressive episode, or depressive symptoms within a manic/hypomanic episode.

A depressive episode is at least two weeks in which a person has at least five of the following symptoms. Intense sadness or despair; feelings of helplessness, hopelessness or worthlessness; loss of interest in activities once enjoyed; feelings of guilt, restlessness or agitation; sleeping too little or too much; slowed speech or movements; changes in appetite; loss of energy; difficulty concentrating, remembering or making decisions; and/or thoughts of death or suicide.

A mania episode is at least one week when a person is high spirited or irritable in an extreme way most of the day for most days. A manic episode involves exaggerated self-esteem or grandiosity, less need for sleep, talking more than usual, talking more loudly and quickly, being easily distracted, doing many activities at once, scheduling more events in a day than can be accomplished, embarking on risky behaviour, uncontrollable racing thoughts, and/or quickly changing ideas or topics. These changes in behaviour are significant and clear to friends and family and are severe enough to cause major dysfunction. A hypomanic episode is a less severe manic episode and need only last four days in a row.

What is the evidence for mixed states in bipolar disorder?

Moderate quality evidence finds the prevalence of mixed states in bipolar disorder is around 35%. The prevalence of mixed states in children with bipolar disorder is around 55%. There were high rates of comorbidities in these children, particularly ADHD, oppositional defiant disorder, and anxiety disorders. The prevalence of mixed states during hypomania is around 27%. The prevalence of mixed states during bipolar depression is around 18%.

Compared to those without mixed features, those with mixed features report more unemployment, rapid cycling, anxiety, and suicide attempts. These were particularly apparent in people in a hypomanic or manic episode rather than a depressive episode.

September 2021

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Bipolar disorder is characterised by recurrent episodes of depression and mania or hypomania. The duration of mood episodes varies from several days to several months, with usually a period of remission in between. The frequency of mood changes (cycling) also varies, with four or more episodes per year classified as rapid cycling.

A depressive episode is a period of at least two weeks when a person has at least five of the following symptoms, including one of the first two. Intense sadness or despair; feelings of helplessness, hopelessness or worthlessness; loss of interest in activities once enjoyed; feelings of guilt, restlessness or agitation; sleeping too little or too much; slowed speech or movements; changes in appetite; loss of energy; difficulty concentrating, remembering or making decisions; and/or thoughts of death or suicide.

A manic episode is a period of at least one week when a person is high spirited or irritable in an extreme way most of the day for most days. A manic episode involves changes in normal behaviour including exaggerated self-esteem or grandiosity, less need for sleep, talking more than usual, talking more loudly and quickly, being easily distracted, doing many activities at once, scheduling more events in a day than can be accomplished, embarking on risky behaviour, uncontrollable racing thoughts, and/or quickly changing ideas or topics. These changes in behaviour are significant and clear to friends and family and are severe enough to cause major dysfunction.

A hypomanic episode is similar to a manic episode but the symptoms are less severe and need only last four days in a row. Hypomanic symptoms do not lead to the major problems that mania often causes, and the person is still able to function.

What is the evidence for mood cycling in people with bipolar disorder?

High quality evidence finds less treatment response in people with continuous cycling bipolar disorder compared to people without continuous cycling.

Moderate to low quality evidence finds the mean annual prevalence of rapid cycling is around 18%, while the lifetime prevalence of rapid cycling is around 31%. This indicates rapid cycling is a transitory phenomenon. Factors associated with rapid cycling include; longer course of illness, earlier age at onset, substance use, and suicidality.

Moderate quality evidence suggests manic episodes peak during spring/summer and, to a lesser extent, in autumn. Depressive episodes peak in early winter and, to a lesser extent, in summer. Mixed episodes peak in early spring or mid/late summer. Moderate to low quality evidence finds menstrual cycle-related mood changes in 44% to 68% of women with bipolar disorder. 25% to 77% met the criteria for premenstrual syndrome, and 15% to 27% met the criteria for premenstrual dysphoric disorder.

September 2021

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Catatonia was originally categorised as a subtype of schizophrenia, but it is found in people with other medical, neurological, and psychiatric disorders, including bipolar disorder. Catatonia is characterised by repetitive non-goal-directed movements or goal-directed movements that are executed in an idiosyncratic way, often affecting gait. Other forms of catatonia include immobility, mutism, staring, and rigidity. Tardive dyskinesia is a ‘hyper-kinetic’ (excessive movement) disorder, characterised by jerky, involuntary movements, usually of the face and/or limbs. Parkinsonism is another common movement disorder associated with schizophrenia and is a ‘hypo-kinetic’ (reduced movement) disorder, characterised by slowness of movement and rigidity. These movement disorders are associated with antipsychotic medications but can arise independent of medication status.

What is the evidence for movement disorders in people with bipolar disorder?

Moderate to low quality evidence finds the prevalence of abnormal involuntary movements in people with bipolar disorder is between 7% and 14%, while catatonic symptoms are found in around 20% of patients.

February 2022

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